Wildland Fires 2014: Is Your EMS Agency Prepared To Respond?

As state and federal government land management agencies prepare for another brutal fire season with less money and fewer firefighters to support operations, one growing need is for emergency medical services and providers who can provide care for wildland fire personnel.

The operational environment is not for the faint of heart or those of weak physical abilities. In short, EMS providers need to be able to work in an environment that is not the typical urban/suburban EMS setting and is without the typical safety net should something wrong; i.e., a hospital is not five minutes away and oh, by the way, you cannot just call up medical control and ask for help.

Also, you can’t mind sleeping on the ground for up to 14 days, eating smoke for that same amount of time, not seeing the constant urban-type EMS calls, and have the ability to miss family days, vacations and birthdays. Providers and agencies actually do sign up for this, but there are special considerations to keep in mind. Is the agency administrator involved, does the provider understand state EMS laws, and do they have medical director and agency administration approval? If not, you have a recipe for disaster.

Each year as wildland fire season rages into blazing infernos involving forests, range-lands and the continually increasing urban-interface locations, EMS agencies and providers need to able to exercise flexibility yet act decisively in constantly changing operational arenas. This includes not only local EMS resources such as ambulances and fire departments that provide response support, but also state EMS bureaus, local emergency departments and medical directors.

Like “traditional EMS,” wildland EMS providers respond to medical or traumatic events, only they do it in the wildland environment. However, like their military medic and combat corpsmen counterparts, wildland EMS providers are also there to help ensure the success of the overall firefighting operation by doing everything possible to ensure firefighters and support staff are at their best and as healthy as possible. That involves a lot of wellness care—something not necessarily covered in most EMT or higher EMS training programs.

Current Agency/Provider Situation

As the fire season approaches each year, EMS agencies and providers, as well as land management agencies, face a mountain of problems related to being prepared to respond, support and provide medical care in an often austere environment.

Many agencies and providers often have no idea how to operate outside of their normal jurisdiction. They often see the dollar signs associated to the deployment of ambulances and providers without seeing the bigger picture of liability or oversight, such as notifying their agency medical director that they have providers in Wyoming when they are licensed in Idaho, having a permission letter from the local response agency to be in their turf, or even getting a local medical director to support them for call-ins, narcotic replacements, etc.

EMS providers fall into five general categories on a wildland fire incident. First there are “embedded” providers. These would be firefighters who are also EMTs or paramedics. These individuals are there to provide immediate care for team members and secondarily for any firefighters from other teams they might be working adjacent to.

The second are line medics. These are EMTs or paramedics who have taken the S-130/190 training and successfully passed a pack test—walking 3 miles in 45 minutes or less carrying a 45 pound pack, the same test all line-qualified personnel have to successfully complete each season to be “red carded.” These medics are out on the fireline to respond to medical incidents and provide ongoing wellness care and monitoring of firefighters. They answer both to their division supervisor and the medical unit leader for the incident.

The third category are “camp medics,” EMS providers at any level who do not have to be line qualified and remain in the base camp to staff the medical unit. The medical unit provides morning and evening “sick call” for crews going out on the line and upon their return, as well as care for camp staff and assisting injured light-duty firefighters who have been kept on the incident but reassigned to a support function. These duties can include dressing changes, blood pressure screening, etc.

The fourth group consists of the contract ambulance and crew. These medics are there to respond out to the line for pick-up of injured or ill firefighters and transport to medical receiving facilities as needed. The crews may be staged in the base camp or, if the incident is large enough, assigned daily standby points to be closer to where they might need to respond.

Lastly, there is the med unit leader and possibly an assistant, the med unit leader trainee. These individuals can be EMS providers of any level who have had specific training in how to administer the provision of medical care to large incidents, including how to operate within the incident command system as well as how to prepare various plans, contingencies, documentation and paperwork. The med unit leader can be an EMT-Basic, which creates an opportunity for providers with little or no experience in the provision of medical care for wildland fire incidents.

A question the may come up is, “How can an EMT-Basic tell a paramedic how to provide patient care?” Simply, the med unit leader is not providing care. They are just there to ensure care is being adequately provided and documented. Additionally, the med unit leader runs bureaucratic interference to ensure care and support are readily available in the most effective and efficient way so firefighters and support staff will remain as healthy as possible, providing the incident commander with the best team to accomplish the mission—containing and putting out the fire.

This isn’t always as easy as it sounds. One problem stems from the very fact that a vast majority of land management agencies do not have medical direction, yet have a huge influx of seasonal employees who are also EMS providers at different training and certification levels (EMR, EMT, AEMT, paramedic, WFR, or WEMT). Some only carry a NREMT certification card, some may have a state license and some receive a wilderness medical training certificate. Yet, most, as noted, do not have medical direction or agency oversight to provide true EMS-related care for their co-workers.

As an example, last summer I dealt with a federal wildland firefighter who took a wilderness EMT course. Part of that course was to take and pass the NREMT exam. He failed the NREMT exam but was still given a WEMT course completion wallet card by the instructor. His supervisor, not knowing how this all works, placed “WEMT” on his incident qualification card and then this individual showed up on a fire I was the medical unit leader on. So, in essence a person failed the NREMT exam, had no medical director, no scope of practice and was still allowed on a fire to try and provide care for people. Someone really dropped the ball there!

Another significant situation involves private contract medical support agencies that may not have a state-issued EMS agency licensure for their providers or their ambulances. Some of that is based on a state’s interpretation of what is an EMS agency and whether or not they need to issue an agency a certificate of necessity because they are not transporting the general public or they do not respond to 9-1-1 calls. This problem can certainly backfire for the private contractor as well as the fire support hiring authority should something go wrong.

An additional concern revolves around military combat medics returning from active duty and being hired by land management agencies. Currently, U.S. Army 68W (68 Whiskey) combat medics receive their NREMT certification through military occupational specialty (MOS) training. Very often they have additional training and skills that can enhance care, such as IV therapy, medication administration and airway management with an endotracheal tube or superglottic device. The problem is once they leave the service many of those individuals lose that medical oversight and liability protection they were once afforded because they’re no longer in the military.

What EMS Is—or Is Not—Doing

One state that has taken a very proactive approach is Idaho. Which makes sense—it’s a state that has one of the heaviest fire loads in the country, is filled with hundreds of thousands of acres of range land, millions of acres of timber and numerous small-to-large urban settings. And it seems each season Idaho is on the National Interagency Fire Center’s (NIFC) situation report for numerous fires.

Other states have allowed providers to be licensed by their home state, but have not required medical direction for that provider. They have given some EMS contractors the ability to operate without a state EMS license because they’re not transporting or caring for the general public. Legally it’s an individual state’s right to allow that to happen. But the question needs to be asked by contracting officers for land management agencies, local jurisdictional EMS authorities, and the providers and contractors themselves, is this the best practice for the protection of the ill or injured? While I am not a man of the law, my best guess is that it’s not a good idea.

With the combination of all those elements, it is not unusual for incident management teams (IMTs) to actively support numerous large fires in a state at once. With each large fire comes a medical unit leader (MEDL) who is required to be an EMT. All too often it’s not known if that MEDL/EMT is actively practicing somewhere, has medical director approval, has authority to be practicing care beyond his or her home agency jurisdiction, or even has a scope of practice to work under.

To help alleviate some of that headache the National Wildfire Coordinating Group (NWCG) Risk Management Committee created the Incident Emergency Medical Subcommittee (IEMS). With the involvement of IEMS, the Clinical Treatment Guidelines for Wildland Fire Medical Units was created to provide a baseline set of directions for occupational-type medical situations. However, that still leaves a very big hole in the system. And I don’t mean just a hole—I mean a crater.

A previously created document that should be in the hands of anyone involved with wildland fire medical care is the Interim NWCG Minimum Standards for Medical Units Managed by NWCG Member Agencies.

It provides a mountain of information as well as recommendations, suggestions and basic guidance for most EMS providers. It needs to be read and understood, and every attempt should be made to follow its ideals. If not, medical malpractice lawyers will be lining up to help families recover financial losses, forcing EMS systems and wildland fire management programs to get their act together.

Suggestions

As you, your agency, your medical director or your system begin the task of preparing for an active wildland fire season within your community, you need to be asking yourself or others some key questions. Are you and your EMS system truly ready to approach or support the task of caring for wildland firefighters in an already non-functioning system? What is your plan to care for the firefighter patients, keep providers out of legal trouble should something go awry, and how does your EMS agency intend to coordinate and communicate with land management agencies for best practices?

Begin with the person who carries the liability of your license. Remember, if you’re not on a wildland fire, that individual is the person who allows you to be employed as a care provider back home. And if you jeopardize your license, you jeopardize his or hers.

• Is the medical director on board and does he or she understand all that you are asking?
• Do they understand you may not be working within their immediate jurisdiction?
• Is their liability/malpractice insurance aware of what you are going to be doing?
• Does your medical director have a way to secure replacement medication should you need it?

Next, move on to the boss—i.e., the person who pays you, as in your normal employer when not on a wildland fire. Remember, they need to be in the loop as to what you’re doing. No one wants to find out after the fact that the reason Jimmy/Susie took vacation was because as an EMT at John Doe EMS they only make $10 per hour but when they go on a fire for the U.S. Forest Service they make $25 per hour or more, and then they get hurt humping up and down the mountain and use the company’s short-term disability. Not a good idea, if you know what I mean.

And if you are what we call a single resource provider on a fire, you have an ethical and moral responsibility to your patient, the agency or system that allows you to affiliate with them, and the medical director that gives you a scope of practice. If you are employed with a primary service and go on wildfires as a way to make extra money with another service, let me remind you that your license from the home unit can be jeopardized if something goes wrong while on that fire. So do yourself and your primary employer a favor and let them know what you are doing ahead of time. In this case, asking for permission and forgiveness after the fact does not bode well.

Conclusion

Some local EMS systems, EMS bureaus/state offices, EMS medical directors and land management agencies have taken a very active approach to this situation. But it’s only after many found out that people where coming into their states unlicensed and providing care that was either outside of the normal local jurisdiction or from local systems filing complaints with state EMS offices.

Others have seen the legal protection and immunity offered to their employees if they are licensed, causing them to seek state EMS agency licensure, which also grants employees a state provider license. While on the other side of the mountain, some land management agencies have completely abandoned the thought of protection for the patient, provider and the agency by providing medical courses and giving an employee a scope of practice that often violates local and state laws.

Land management agencies as a whole have a responsibility to work with local systems and state EMS regulatory boards. It needs to happen before the fire season, not when all hell is breaking loose and people are running from the fire while others run in.

Some are attempting to do that and that’s admirable. But many are not, and while there is discussion about an interstate compact to allow licensed providers within the fire programs the ability to move state-to-state, these things take time. States and federal agencies both need to develop that system in a coordinated effort that is constantly communicated to all interested parties. Let’s remember the 2008 Dutch Creek Incident and not wait until another firefighter dies because of the inability to work together with our emergency services family.